Part 2 Common Pathologies of the Lumbar Spine

8/3/2019 Part 2 Common Pathologies of the Lumbar Spine

1/31

Welcome to At Home Seminars!

Attached with this letter is your electronic download course. A copy of your onlinetransaction has been emailed to you and a hard copy will follow in the mail in a coupleof business days. You can also access your invoice from your online account at ourwebsite (www.athomeseminars.com).

The following pages will contain your course module which contain your coursesdirections, goals, and objectives, post-test examination, reading materials (if applicable),test answer sheet and course evaluation form. Please read the page entitled, How toTake this Course, in the following pages and read all of the directions before beginningyour course. We recommend that you print, at the minimum, your post-test questionsand answer sheet before beginning your course.

After you have completed the reading material, you will need to complete the post-testexamination. You may utilize your course materials to answer the questions. Clearlywrite your answers to all of the questions on your answer sheet with a black pen. Whenyou are finished, you may either mail or fax the answer sheet back to us to be graded,or you may login to our online testing center from our website and input your testanswers yourself. If you choose to fax or mail your answer sheet, return only theanswer sheet and not the entire test. If you enter your answers into our online testingcenter or fax your answer sheets you do not need to return your original answer sheetsto us. If you score 75% or higher on the test, you will be issued a certificate ofcompletion for the contact hours specified for the course. Customers, who wish to knowthe answers to the questions they have missed, must take their tests online to see thecorrect answers. At Home Seminars office personnel cannot answer questions aboutpost-test questions or provide correct answers to the questions you may have missed onyour examination.

Finally, please be sure that you clearly and completely fill out the bottom of youranswer sheet with your name, address and licensure states as well as the type of license(PT/OT/ATC), and your license numbers if you are returning it to us. This will help toinsure that we can report your continuing education hours accurately to the states thatrequire it.

Please also keep in mind that you have one-year from the invoice date to complete yourcourses and return them to At Home Seminars. Courses returned after the one-year

deadline will be subject to an additional charge.

We hope you enjoy your courses!

Sincerely,

At Home Seminars, LLC
http://www.athomeseminars.com/http://www.athomeseminars.com/


2/31

PRESENTS:

Current and Popular Concepts

In the Evaluation and Non-Operative Treatment

Of the Lumbar Spine

PART TWO:

Common Pathologies of the Lumbar Spine

By Jeffrey P. Larson R.P.T., A.T.C.Illustrations by Edward R. Prather

A Self-Paced study


3/31

i

Current and Popular Concepts In the Evaluation and

Non-Operative Treatment Of the Lumbar Spine

Part Two: Common Pathologies of the Lumbar Spine

a self-paced study distributed by At Home Seminars

About the Author and Illustrator:

Jeffrey P. Larson R.P.T., A.T.C. is a practicing Physical Therapist, Certified Athletic

Trainer and free-lance medical writer and sports medicine coordinator who resides in

Fargo, North Dakota. He has worked extensively in the field of Sports Medicine as both

a Physical Therapist and a Certified Athletic Trainer and currently is a Sports MedicineCoordinator and practicing Physical Therapist with Healthsouth in Fargo, North Dakota.

He has published many articles in medical as well as layman periodicals and is a member

of the American Medical Writers Association. Much of his writing focuses on continuing

education for allied healthcare professions as well as consumer health education.

Education: B.S. Athletic Training, Minor in Biological Sciences; North Dakota State

University; B.S. Physical Therapy Cum Laude; University of Utah.

Edward Prather graduated from Concordia College in Moorhead, Minnesota with a BA

degree in Art and also with a commercial art degree from Moorhead. Edward continued

his study at Atelier Lack School of Fine Arts in Minneapolis, Minnesota studyingtechniques of the Old Masters. He has worked as a full time illustrator for a studio in

Minneapolis that did illustrations for science and medical textbooks. Currently, Edward

is a freelance artist living in rural North Dakota with his wife and three children.

Copyediting/proofreading: Jeffrey K. McCamman, MPT

Illustrations: Edward R. Prather

Design/production: At Home Seminars


4/31

HOW TO TAKE THIS COURSE

1. Before you begin, check your answer sheet and make sure your course identification number matchesthe number listed on your invoice. If the numbers are incorrect, please contact us immediately so that

corrections may be made.

2. Read the Behavioral Objectives. They provide specific learning goals and an overview of thecourse.

3. Read the material in the order presented. If you need help with the material, you may contact us bytelephone, mail or by email at: [email protected].

4. Complete the post test examination and course evaluation form. Follow directions and give usaccurate, complete information. Incomplete or illegible information delays or prevents processing of CE

credit. Course materials may be used to assist in answering the post test questions. Completion of the

Course Evaluation Form is not mandatory, however it does help us to evaluate the quality of our courses

and to alert us of any problems that may be present.

5. Complete the examination carefully. The answer sheet will not be returned to you but a letter will

accompany your completion certificates stating your grade for each course. A score of 75% or more isconsidered passing. Scores of less than 75% indicate a failure to understand the material and At HomeSeminars will call you by telephone to correct the examination with you. An answer sheet with a passing

grade must be present in our files for CEU credit to be assigned.

6. Office personnel are unable to answer questions regarding test questions or answers. To view thecorrect answers for the questions you may miss on your examination, you must complete your test through

our online testing center. If you have problems or questions with a test question, please note it in the

Comments portion of your answer sheet or when taking your test online.

7. Return your post test answer sheet or take your test online. Customers have the ability to activateonline testing at no charge from their online account page on our website. You may also return your

answer sheet by mailing it to At Home Seminars, PO Box 94594 Las Vegas, Nevada 89193 or by faxing

it to: 1-800-959-3328. Please do not use UPS, Fed Ex, or Certified Mail to return your tests as it delaysprocessing. If you fax your answer sheet, please be sure your answers are printed legibly in black ink.If you fax your answer sheet to us or take your test online, you do not need to return your original answersheets to us. The date that your envelope is postmarked , the day your test is received by fax, or the day you

complete your test online will be the date of completion printed on your certificate of completion.

8. Certificates are generally returned within 3-4 days of receipt by our office. Examinations areprocessed in our office within 1 business day of receiving them and then certificates are mailed by 1

stClass

Mail to you. Certificates can be faxed to you before mailing upon request at no charge as long as the

request is made at the time the test is submitted.

9. Passing tests will be kept at our office for a period of seven years from the date of completion. Ifyou lose your certificate you can print another copy from your online account or contact us and well be

glad to assist you.

10. You have one-year from the invoice date to complete this course and return the answer sheet to us.Tests returned after the one-year deadline will be subject to an additional charge of $20 per course forprocessing and run the risk of no longer being valid in your state.

11. By placing this order, you have been placed on our preferred mailing list. This allows us to send you

information as new courses become available or as special offers are available. At Home Seminars doesnot sell its mailing lists.


5/31

iii

Target Audience:

Physical Therapists, Physical Therapist Assistants, Occupational Therapists,

Occupational Therapist Assistants, Athletic Trainers

Instructional Level:

Beginner

Course Goals:

This course is intended to facilitate a review as well as a learning experience for the

therapist, athletic trainer, and other related professionals through a self-paced study of

the common pathologies of the lumbar spine.

Student Objectives:

At the end of this course the student will be able to:

1. Identify the pathologies involving the bony structures of the lumbar spine

2. Specify the ligamentous and muscular strains seen in the lumbar spine.

3. Identify the pathologies involving the intervertebral disc of the lumbar spine

4. Identify the degenerative changes seen in the lumbar spine.

5. Identify the influences of fibromyalgia upon low back pain.


6/31

iv

Course Outline:

Common Pathologies of the Lumbar Spine

A. Introduction

B. Fractures

1. Stress Fractures

2. Compression Fractures

3. Osteoporosis and Fractures of the Lumbar Spine

C. Lumbar Strains and Sprains

1. Muscles and Myofascial Structures

2. Piriformis Syndrome

3. Ligament Strains

4. Facet Joint Impingement5. Facet Joint Sprain

D. Boney Structural Defects

1. Spondylolysis

2. Spondylolythesis

E. Vertebral Disc Pathology

1. Intervertebral Lumbar Disc Herniation

F. Degenerative Diseases of the Lumbar Spine

1. Facet Degenerative Joint Disease2. Lumbar Disc Degeneration

3. Lumbar Stenosis

a. Lateral Stenosis

b. Central Stenosis

4. Degenerative Spondylolythesis

5. Osteoarthritis

6. Ankylosing Spondylitis

G. Other Considerations in the Origin of Lumbar Spine Pain

1. Fibromyalgia

2. Other Considerations

H. Bibliography


7/31

POST TEST

Directions: After reading the previous material, answer the questions on this post test

and return your answer sheet to At Home Seminars. You may utilize the learningmaterials to answer the questions. Upon receipt of your test, it will be graded, and if you

score 75% or higher, we will issue you a certificate of completion.

CURRENT AND POPULAR CONCEPTS IN THE EVALUATION

AND NON-OPERATIVE TREATEMNT OF THE LUMBAR SPINE

PART TWO: COMMON PATHOLOGIES OF THE

LUMBAR SPINE (COURSE #208)

1. The type of fracture that is more likely to occur when an individual increases his

or her training intensity or changes the nature of the activity in an abrupt manner

is known as

A. Stress fracturesB. Compression fractures

C. Burst fractures

D. Displaced laminar burst fractures

2. An individual falling from a height and landing on both feet or the buttocks is an

excellent example of the mechanism for which type of fracture to the lumbarspine?

A. Stress fracturesB. Compression fractures

C. Burst fracture

D. B and C

3. Reduced bone strength of the lumbar spine may be the result of

A. OsteoporosisB. Lumbar myofascial pain

C. Postmenopausal changes

D. A and C


8/31

4. The diagnosis of acute low back pain often

A. Is non specific

B. Encompasses ligament and muscle strains.C. Is the result of stress fractures

D. A and B

5. Inflexibility of what muscle group places stress on the lumbar spine during

flexion?

A Hamstrings

B. Quadriceps

C. AdductorsD. Hip external rotators

6. A common cause of low back pain resulting from irritation of the nociceptive

system of lumbar muscles is

A. Myofascial pain

B. Piriformis syndromeC. Facet joint impingement

D. Lumbar stenosis

7. It is very common to see an individual experiencing a combination of a lumbar

ligament sprain and lumbar muscle strain from a single injury.

A. True

B. False

8. Facet locking in the lumbar spine may present as

A A patient locked in a position of side bending to the left and rotation to the

right.B. Pain and/or restriction of movement when the patient attempts movement

in the direction opposite the position in which he or she is locked.

C. Restrictions of lumbar flexion but not rotationD. A and B

9. Actual slipping of one spinal segment on another spinal segment is known as

A. Spondylolysis

B. SpondylolythesisC. Facet joint impingement

D. Dysplastic Spondylolysis


9/31

10. Which type(s) of spondylolisthesis are most commonly seen in children and

young adults?

A. Dysplastic spondylolisthesis

B. Isthmic spondylolisthesisC. None of the aboveD. A and B

11. The condition in which the nucleus pulposus is forced outward placing pressure

on a spinal nerve is referred to as all of the following except

A. Herniated nucleus pulposus

B. Disc translationC. Ruptured intervertebral disk

D. Disc extrusion

12. The classification given to a disc bulge that does not rupture the

fibrocartilagenous annulus fibrosis is called

A. Disc protrusionB. Disc prolapse

C. Disc extrusion

D. Sequestrated disc

13. The most common level of the lumbar spine affected by disc herniation is

between

A. The fifth lumbar vertebra and the first sacral vertebra

B. The fourth and fifth lumbar vertebraeC The third and fourth lumbar vertebrae

D The first and second lumbar vertebrae

14. Herniation of the disc between L4 and L5

A. Will compromise the fifth lumbar rootB. Will involve all the nerve roots of the cauda equina

C. May result in bowel and bladder paralysis

D. Will compromise the fourth lumbar root


10/31

15. Which of the following statements is not true?

A. The peak age for the incidence of disc herniation is between 20-45 years

of age.B. Males are more commonly affected than females by lumbar disc

herniation.C. Studies show that bulging and protruding discs appear on scans of up to60% of people who have no back pain at all.

D. Disc material extruding outside the vertebrae and breaking off from the

disc most likely is not a cause of pain.

16. Degenerative changes referred to as a disease in the vertebral disc joints

A. Is often termed spondylosisB. Presents the development of osteophytes along the junction of vertebral

bodies and discs

C. Results from the natural stresses placed upon the spine throughout lifeD. All of the above

17. An abnormal condition characterized by a narrowing of the lumbar spinal canal or

neural foramina is called

A. Degenerative spondylolisthesis

B. Lumbar stenosisC. Facet impingement

D. Isthmic spondylolisthesis

18. Osteoarthritis of the lumbar spine can be described as all of the following except

A Disc height and volume of the vertebral segments are lost

B The bones associated with the joints develop abnormalities

C Nerves may become pinched, causing pain and numbnessD Lumbar spine mobility remains unaffected despite the potential for

osteoarthritis to affect cartilage

19. Which of the following lumbar spine conditions is described as inflammation ofone or more vertebrae followed by stiffening and decreased mobility?

A. Isthmic spondylolisthesisB. Central stenosis

C. Ankylosing spondylitis

D. None of the above


11/31

20. Widespread muscle pain, fatigue, and multiple tender points may characterizewhich condition

A. Facet Degenerative Joint DiseaseB. Piriformis Syndrome

C. Isthmic spondylolisthesD. Fibromyalgia

21. How would you rate this course of a scale of 1 to 7 (1=not informative,

7=extremely informative)

___________

22. How long did it take you to complete this course?

A. Less than 2 hoursB. Between 2 and 3 hours

C. Between 3 and 4 hours

D. Between 4 and 5 hours

E. More than 5 hours

23. Would you recommend this course to others?

A. YesB. No

If No, why not? _________________________________________________

7


12/31

Common

Pathologiesof the

LumbarSpine

1


13/31

Introduction

Physical therapists and related healthcare professionals have become increasingly

involved with the evaluation and assessment of the patient with low back pain. The origin of over

80% of back pain cases is unknown, however a number of conditions are found that may make

some individuals more susceptible to low back pain.1 Most often pain to the lumbar spine begins

with an injury such as after lifting a heavy object, or after making an abrupt movement. In other

cases, the onset is not so easily detectable.

In part one of this lumbar spine series, basic anatomy and biomechanics was discussed

establishing a foundation explaining the functional anatomy of the lumbar spine in a non-

pathological state. Part two of this series will take the clinician one step further toward treating

the patient experiencing lumbar spine pain. An understanding of the common pathologies of the

lumbar spine becomes an essential link in formulating the information needed to appropriatelytreat each patient as effectively as possible.

Treating low back pain is often a complex and perplexing challenge. Having an

understanding of lumbar spine pathology does not by itself lead to a full understanding of the

patients symptoms. This leaves many questions unanswered concerning the origin of low

back pain. For example, one patients disc pathology may be identied by a myelography

and determined to be the cause of the patients complaint. The disc problem is then surgically

corrected but the patients signs and symptoms remain unchanged. Now in another instance, the

CAT scan identies the same lumbar disorder with appropriate measures taken by the physical

therapist resulting in the patients symptoms disappearing. Yet, on a follow-up CAT scan the

problem remains unchanged. The point is that much literature still states that there is often no

clear-cut cause and effect relationship between what we see or what we think we see and what

may actually be causing the patients problem.2 Yet, the clinician must have a knowledge base

of the lumbar spine that has either undergone trauma, disease, or the natural aging process

before one can even postulate the origin of the pain. Following are several of the more common

pathologies presented in the clinic by the patient who is experiencing pain to the lumbar spine.

2


14/31

Fractures

Stressfractures

Stress fractures are common injuries among athletes and can involve the lumbar spine as

well as other regions of the body. This is often the case when participants increase their training

intensity or change the nature of their activity in an abrupt manner. A good example of this is

college freshman athletes as they nd themselves engaging in more intense levels of training and

competition compared to their high school athletic experiences. The pain usually has an acute

onset presented as nonspecic with discomfort localized to the lower lumbar region limiting the

patient in lumbar exion and extension. 3

Stress fracture of the pars articularis is a potential condition as this structure becomes

subject to severe angular forces from certain activities, especially in sports such as football

and gymnastics. 4, 5,6,7 A lumbar stress fracture through a facet is noted as a rare injury and is not

mentioned as a signicant lumbar spine pathology throughout current literature. 3

Compression fracture

An individual falling from a height and landing on both feet or the buttocks is an

excellent example of the mechanism of injury that may produce compression fractures.

A more specic type of compression fracture is described in some literature as a lumbar burst

fracture. This specic type of fracture is often the result of a fall landing on the feet or buttock.

Burst fractures involve a compressive failure of the vertebral body both anteriorly and posteriorly

with localized failure of both anterior & middle columns. 4

Injury patterns for burst fractures vary with the anatomic level involved. For example,

L1 to L3 pedicles are frequently r detached whereas levels L4 to L5 fractures usually present a

consistent pattern where pedicles of this level usually remain intact. Although displaced laminar

fractures may entrap the dura and cauda equina, neurologic injuriesarising from lumbar burstfractures are less common and have a better prognosis than neurologic injuries arising from

thoracolumbar burst fractures. 4

In the younger and athletic population, compression fractures frequently occur as a result

of violent hyperexion of the trunk. Fractures of the transverse and spinous processes result most

3


15/31

often from kicks or other direct blows to the back. Since large muscles surround these processes,

fractures can produce extensive soft tissue injury. In the elderly, falls causing compression

fractures become more likely because the vertebral bodies and surrounding boney structures

become more brittle. 4

Osteoporosis and Fractures of the Lumbar Spine

Osteoporosis is generally a decrease in bone mass and strength causing susceptibility

to fractures. It is a major cause of bone fractures in postmenopausal women and older persons

in general. The beginning of osteoporosis is unclear, and until recently before more advanced

testing, its rst visible sign was a vertebral fracture causing back pain or deformity. 8

Bone formation and re-absorption enable bones to remodel and serve as a calcium

reservoir in the body. After age 35 everyone begins to lose very small amounts of bone. Some

women are predisposed to osteoporosis by achieving only a very low adult bone density. After

menopause, the disease is more common in women. Bone loss of the lumbar spine results in

reduced bone strength that can easily lead to fractures of the spine in general. An increased

likelihood of developing osteoporosis may result from early menopause, whether natural or

surgical. 5,8,9

A high consumption of alcohol, caffeine, or cigarette smoking has been linked to

osteoporosis. Some medication, such as long-term corticosteroids will increase the likelihood

of this disease and low back fracture. A low dietary intake of calcium over a prolonged time,

especially during adolescence or young adulthood is a predisposing factor as well as a diagnosis

of scoliosis.4 In addition to low back pain caused from a vertebral fracture, debilitating fractures

of the hip and wrist are also common sites of fractures resulting from osteoporosis. 8

Lumbar Sprains and Strains

Muscles and Myofascial Structures

Resulting in much of the acute and intense low back pain seen in the clinic, the common

diagnosis of acute low back pain is often referred to as non specic which encompasses

ligament and muscular strains.6 Regardless of the underlying cause, muscle guarding and or

intrinsic muscle spasms usually accompany other origins of spinal pain. One example of this

4


16/31

is the secondary muscle spasms that may accompany the patient with a vertebral fracture or a

herniated lumbar disc. Research has helped dene this associated pain by explaining the action

of peripheral bers of the annulus brosis. These are innervated by nociceptive nerve bers

responsible for pain messages. The afferent branches of these nerve bers uniquely innervate

the paraspinal muscles. The resulting muscle spasms associated with this clinical syndrome arethought to be produced by an undetermined sensory or motor reex of low back pain pathways.

The primary role of muscle injury in the production of low back pain remains uncertain even

though strains and sprains of the lower back are the most commonly diagnosed. 1, 6

Primary muscular disorders may be classieds as strains, contusions, and inammations.

Despite their size and strength, muscles supporting the lumbar spine can strain as a result of a

heavy load or sudden force applied to the muscles before they are ready for activity. The muscle

essentially tears along with the blood vessels being stretched and torn within the muscle tissue.

This results in an outpouring of blood into the area followed by pain and inammation leading

to muscle spasms. It can take up to two to three hours before sufcient bleeding or irritation sets

in to produce disabling pain. This can help explain why many people often can tolerate nishing

the task at hand, only to suffer from intense pain later.6

During repetitive demands of trunk extension and rotation, the primary muscles at risk to

lumbar strain are the erector spinae, and the multidis. However, also deserving of mention are

the abdominal muscles which can also be potentially injured from repetitive trunk exion and

rotation. These posterior and anterior muscle groups function synergistically in an alternating

concentric-eccentric fashion to allow smooth trunk movement. As with any other muscle group,

repetitive lumbar muscle contraction eventually leads to muscle exhaustion, ischemia, and

the accumulation of local lactic acids. 1,5 Lumbar muscle spasms often result from repetitive

extension, exion, and rotation against poorly exible muscles and ligaments. This creates a

repetitive stress on these lumbar soft tissues, ultimately causing tissue damage through repetitive

microtrauma. An important clinical implication is that hamstring inexibility places greater

stress on the lumbar spine exion, thereby straining the back extensor muscles and posterior

spine ligaments. Primary muscle disorders such as strains and sprains, are often termed. a young

mans injury and usually heal despite the care given. However, stiffness, weakness, and posturalchanges may occur during the healing process placing emphasis on the need for appropriate

rehabilitation. 1, 5

Myofascial pain is one of the common causes of primary low back pain resulting from

irritation of the nociceptive system that is distributed throughout the muscles and fascia of the

5


17/31

lumbar region. Far more often, low back pain of myofascial origin is the result of muscular

fatigue, reex muscle spasm or trauma. 1 For example, current literature lists the most

common cause of low back pain seen in athletes as overuse with resultant strains or sprain of

the paravertebral muscles and ligaments. Generally, a muscle strain produces localized pain,

however, acute low back pain from lumbar strains and sprains can be accompanied by sciatica.Myofascial restrictions may also occur from overuse or overstrain and will also accompany other

types of injury in low back pain. 1, 5

Piriformis Syndrome

The piriformis syndrome has been seen to occur when an injury or muscle spasm of the

piriformis compresses and irritates the sciatic nerve running next to, or in some individuals,

within this particular muscle. 10 This spasm or irritation of the piriformis muscle can be the result

of tight or overworked hip and lumbar muscles. Activities such as excessive bending of the

lumbar spine beyond a comfortable range too quickly can overwork this muscle and cause severe

spasm. This may not only produce pain for the patient, but also cause weakness in the lumbar

region, buttock, or posterior hamstring muscle. The patient may describe a deep, dull ache on the

side where the sciatic nerve enters the thigh from the pelvis, or where the hip and buttock meet.

10

While piriformis syndrome pain may radiate down the legs, it rarely goes below the

knee which is seen in sciatica from other nerve irritations such as a herniated disc. A complaintof dull ache after activities such as climbing stairs or walking up an incline is common.

Biomechanically, any signicant leg-length differences can also put an increase of pressure onto

the piriformis muscle causing a painful spasm. Other possible irritants to the piriformis muscle

from excessive pressure on the muscle leading to lumbar pain are sitting incorrectly for an

extended amount of time in a poorly supported chair as well as tight hip exors. 5,10

Ligaments

Lumbar sprains refer to an overstretching of one or more of the lumbar ligaments.

5,7,8 A ligament of the lumbar spine can be either mildly stretched beyond its natural integrity

causing only temporary pain and loss of function or stretched to the extent of causing complete

disruption. It is very common to have both lumbar ligament sprains and lumbar muscle strains

occurring together from an injury. This is especially the case in severe falls, more serious athletic

injuries, and motor vehicle accidents.5,10

6


18/31

It is generally recognized that ligamentous pain arises from a weakened ligament, which

when stretched, will produce pain and perhaps trigger muscle guarding. Traumatic ligament

sprains include exion strains, which exceed limits of the interspinous ligament and supraspinous

ligaments. A typical patient with this type of lesion is a middle-aged person who complains of asudden onset of one-sided back pain localized to the fourth and fth level in the lumbar spine.

The clinician will sometimes also nd the patient complaining of pain radiating down the gluteal

region. 5,10

Facet Joint Impingement

Impingement of the facet joint is described as a mechanism in which the synovial and

capsular tissue which line the facet joint capsule become impinged between the joint surfaces.

Pain and/or restriction of movement will be present when the patient attempts movement in thedirection opposite the position in which he or she is locked. For example, facet locking in the

lumbar spine may be presented from a patient locked in a position of side bending to the left and

rotation to the right. In this case, pain and/or restriction will be noticed when the patient bends to

the right and rotates to the left. 5, 9,10

Facet Joint Sprain

Facet sprain presents a history of moderate to severe trauma enough so that the examiner

must consider the possibility of joint sprain with effusion in and around the joint. Some authors

believe that pathological processes of the facet joint occur after, and perhaps because of, disc

degeneration. Others believe that they occur with disk degeneration. Asymmetry of the facet

joints is well documented and has been given particular signicance by some researchers as a

contributing factor to pathologic problems in the lower lumbar region. 5, 10

Boney Structural Defects:

Spondylolysis and Spondylolythesis

Spondylolysis denotes the loosening of the vertebra whereas spondylolythesis refers to

the actual slipping of one spinal segment on another spinal segment. 4, 5, 6, 7

These two particular back disorders are quite common with documentation as high as 90% of

cases found in athletes with spondylolythesis and spondylolysis involving L5. Spondylolysis

7


19/31

can originate as

a small crack in

the arch portion

of the vertebrae;

however, manyagree the crack is

not present at birth

but comes on with

increasing age and

activity (Figure1).

Several authors

have noted that

some physically

demanding

activities may

increase the rate

of spondylolysis.

When the arch

becomes cracked

through the entire

vertebral body, it

is no longer linkedwith the rest of the

vertebral segment.

As a result, the

vertebral segment

is now free to move and slide forward on the element just below it. This slipping forward is

called spondylolythesis.4, 6, 10

Physicians and researchers commonly divide this slipping into four categories. These

categories reect the amount that one block of bone slips forward on its mate below. If it slips

one-fourth the way it is called a grade one. Grade two is a half way slip, grade three is a three-

quarter slip and a grade four is a complete slip 9 (Figure 2).

Spondylolythesis can further be classied as dysplastic, isthmic and degenerative

spondylolisthesis. 4

Figure 1: Illustrated Version of Spondylolysis.

8


20/31

Dysplastic spondylolisthesis involves a congenital insufciency of facet joints of the

S1 or L5 joint complex. This results in displacement without a defect of pars articularis. The

fth lumbar facets appear to subluxate forward on the sacral facets. Pedicles can also appear

elongated and may contribute to the forward subluxation when slip is signicant. These patients

become more prone to recurrent symptoms and deformity if forward slipping is allowed to

progress. During dysplastic spondylolisthesis, there is a high occurrence of nerve root pressure

due to intact lamina of L5 being pulled against the dural sac. Because of this, signicant

neurologic impairment may occur in the presence of only minor degrees of slip. 4

Isthmic spondylolisthesis, occurring in about 5% of the population, is the most common

Figure 2: Meyerding Grading System for Slipping in Spondylolisthesis

9


21/31

type of spondylolisthesis seen in children & young adults. This is especially the case in young

individuals involved in activities of hyperextension placing increased shear stress at pars intra-

articularis. Isthmic spondylolisthesis is usually seen at L5-S1 and usually presents with back pain

resulting from instability. Kyphosis of lumbosacral junction may also be noted with or without

palpable step off. L5 radicular ndings may be associated in the case of severe slips.4

Vertebral Disc Pathology:

Intervertebral Lumbar Disc Herniation

Excessive pressure from the vertebrae above and below can cause the nucleus pulposus to

be forced outward placing pressure on a spinal nerve causing considerable pain and damage. This

condition frequently occurs in the lumbar spine and is also commonly referred to as herniated

nucleus pulposus, ruptured intervertebral disc, or slipped disc. A herniated disc is also the most

common cause of severe sciatica which is the result of the pressure on the nerve roots or on the

spinal cord, causing a shock-like

pain down the legs, weakness, numbness or problems with bowels, bladder or sexual function.4, 5, 7

Figure 3: Disc Protrusion with Pressure Upon Nerve Root

10


22/31

When describing the specic mechanics of disc pathology, there are four classications

which often vary in the literature. First, a protrusion may occur where a disc bulges without

rupturing the brocartilagenous annulus brosis (Figure 3). Secondly, the disc may prolapse

where the gelatinous center portion called the nucleus pulposus migrates to the outermost bersof the annulus brosis. Thirdly, there may be a disc extrusion, which is the case if the annulus

brosis perforates or herniates and material of the nucleus moves into the epidural space. Lastly,

the sequestrated disc may occur as fragments from the annulus brosis and nucleus pulposus that

are outside the disc proper 7 (Figure 4). Occasionally, after an annular tear, a thin layer of scar

tissue at the periphery of the tear may seal the leak but leave the disc highly susceptible to re-

tearing. 4,7,9

The most commonly affected level of the lumbar spine affected by disc herniation is

between the fth lumbar vertebra and the rst sacral vertebra. Studies show that in the general

population, as high as 98 percent of disc prolapses are at the L4-L5 or L5-S1 level. 4 Herniation

of the disc between L4 and L5 will compromise the fth lumbar root. Large herniation of the L5-

S1 disc will compromise not only the nerve root crossing it

(fth lumbar root) but also the nerve root emerging through the same foramen. Massive central

sequestration of the disc at the L4-L5 level will involve all the nerve roots in the cauda equina

and may result in bowel and bladder paralysis. 1, 4,

Any direct, forceful, and vertical pressure on the lumbar discs can cause the disc topush its uid contents into the vertebral body. Herniated nucleus pulposus may occur suddenly

from lifting, twisting, or direct injury or it can occur gradually from degenerative changes with

episodes of intensifying symptoms. The annulus may also become weakened over time allowing

stretching or tearing leading to a disc herniation. In general, annular tears are usually produced

by injury that increases intradiscal pressure. Any strenuous activity placing the lumbar spine

in repetitive

rotation

combined with

hyperextension

places the disc

at an increased

risk of annular

tears. Figure 4: Visual Examples of Protrusion, Prolapse, Extrusion and Sequestration of aDisc

11


23/31

Predisposing factors associated with disc herniation include age, gender, and work

environment. The peak age for the incidence of disc herniation is between 20-45 years of

age. Studies have shown that males are more commonly affected than females in lumbar disc

herniation by a 3:2 ratio. Although prolonged exposure to a bent-forward work posture is

correlated with an increased incidence of disc herniation, studies are nding that bulging andprotruding discs show up on the scans of up to 60% of people who have no back pain at all.

Experts now generally believe that bulging or even protruding discs may be normal and do not

necessarily indicate serious back problems. One expert suggested that discs might even swell in

response to stress and then contract again. However, most researchers and clinicians agree that

disc material extruding outside the vertebrae and breaking off from the disc is most likely the

cause of pain.

Clinicians need to be cognizant that sciatic pain is also sometimes present when there is

no evidence of a bulging or extruding intervertebral disc. For example, cases have been reported

of chronic low back pain caused by inward growth of nerve bers into intervertebral discs along

with nerves in the outer ring of the disc being the primary source of pain. 4 Why some patients

with a herniated lumbar disc suffer painful sciatica while others continue through life with

painless herniations of the same size is still one of the greatest mysteries of the lumbar spine and

creates a clinical problem of signicant impact.

In one study in an attempt to nd the differences between symptomatic and non-

symptomatic disc problems, 30 patients were observed having severe sciatica requiring discsurgery. In the same study researchers studied 46 asymptomatic volunteers. In this group,

researchers were able to match up 22 asymptomatic and symptomatic disc herniations that could

be coordinated according to age, disc level, and extent of the herniation. The study showed

researchers that symptomatic disc herniations exhibited signicantly shorter relaxation and

painless episodes than matched asymptomatic herniations. The symptomatic herniations also

demonstrated signicantly greater levels of disc degeneration. The researchers interpretation

was that asymptomatic disc herniations at an early stage may eventually become symptomatic

with advancing age. Also noted was that specic biochemical alterations of the intervertebral

disc may be responsible for the fact that one disc herniation is symptomatic and another similar

herniation is asymptomatic. 2

12


24/31

Degenerative Diseases of the Lumbar Spine

Facet Degenerative Joint Disease

Facet degenerative joint disease is a degenerative disease also known as facet syndrome,

osteoarthrosis, or degenerative joint disease. This condition is aggravated by hyperextension

and twisting of the lumbar spine with leg pain often present. Although facet degenerative joint

disease can be painful and debilitating, an argument exists against viewing spinal osteoarthrosis

as a disease because it is not usually associated with symptoms and disabilities. 4, 9 Studies show

the incidence of osteoarthrosis is just as great in patients without symptoms. Physicians use

oblique x-rays or CT scans to indicate facet degeneration in helping to nalize the diagnosis.

Facet joint pain can be referred to any part of the limb but most commonly to the gluteal and

proximal thigh regions.4

Lumbar Disc Degeneration

Figure 5: Degenerative Joint/Disc Disease in the Lumbar Spine

13


25/31

Early biomechanical and structural changes related to aging have been identied in the

nucleus pulposus and annulus brosis. Any additional trauma upon these changes facilitates

the process of degeneration. An example of this traumatic degeneration is a compression injury

causing an end plate fracture that can predispose the disc to degeneration in the future. 4, 5

Degenerative changes referred to as a disease in the vertebral disc joints is often termed

spondylosis. The main feature of spondylosis is the development of osteophytes along the

junction of vertebral bodies and discs resulting as a natural consequence of stresses applied to

the spine throughout life. When disc degeneration occurs, the layers of the annulus can separate

in places and form circumferential tears. Several of these circumferential tears may combine

to form a radial tear where the nuclear material may herniate producing a disc herniation or

prolapse. Even if a disc herniation does not occur, the annulus weakens with circumferential

bulging and associated loss of disc height. 7, 8

Disc narrowing occurs naturally as a result of the alteration of the nucleus pulposus from

a gelatinous consistency in childhood to a brous consistency in adulthood. 5, 9 This results in

the reduced disc volume by loss of water and mucopolysaccharides. Genetics appears to have a

signicant impact on the degenerative process (Figure 5).

Lumbar Stenosis

Stenosis of the lumbar spine is an abnormal condition characterized by a narrowing of the

spinal canal or neural foramina producing root ischemia and what is termed neurogenic claudication.

Compression of neural structures also compresses vascular supply of nerves so that symptoms are

predominately those of neural ischemia. Because both the neural canal and the neural foramen are

narrowed with the spine in extension and opened in exion, pain is usually described as occurring

when the patient is upright, particularly when walking. Typical symptoms are leg pain, numbness

and weakness developing after the patient walks a predictable distance. Patients will often nd

relief by sitting or leaning forward to relieve the pressure. It is important for the clinician to

note that ten percent of adults over the age of sixty-ve may have this nding with many being

asymptomatic. Lumbar stenosis can be further divided into lateral and central stenosis. 4

Lateral Stenosis

Lateral stenosis is characterized by the lateral part of the spinal canal becoming narrowed

by entrapment of the spinal nerve causing symptoms. At rst, the pathological ndings are

14


26/31

subluxation of the facet joint and narrowing of the lumbar vertebral disc. Because of the oblique

orientation of the facet joint surfaces, the superior articular process of the lower vertebrae moves

forward as well as upwards. As the joint subluxates, extension and rotation of the spine cause

further forward displacement of the superior articular process. The facet joint capsule thickensand the articular process enlarges. Osteophytes often form around the articular processes and

discs. In some cases, two pairs of spinal nerves can be trapped at any one level. 4

Central Stenosis

Central stenosis results from the narrowing of the center of the spinal canal and may

be developmental or acquired. In the case where this condition is the result of degenerative

changes, central stenosis may accompany osteophytic enlargement of the inferior articular process

and thickening of the laminae. In both of these events, the spinal canal becomes narrow from

behind. Osteophytes form on the corners of the vertebral bodies resulting in a narrowing of the

canal from the front. The result can be extreme narrowing of the canal through which the cauda

equina and dural sheaths must run. Multi level stenosis may lead to progressive degeneration

from one level to another. The nal stage of this process is severe degenerative disease of

the lumbar spine, with both central and lateral stenosis at every level and nerve 4 (Figure 6).

Figure 6: Views of Normal Foramina, and Foramina with Central and Lateral Stenosis

15


27/31

Degenerative Spondylolisthesis

Degenerative spondylolisthesis often occurs as a result of degenerative disc disease and

facet deciency. It is a combined result of disc narrowing and posterior joint degeneration and

subluxation. In this condition, there is a marked loss of articulator cartilage in the posterior

joints, which allows the upper vertebrae to slip forward on the lower vertebrae as the discnarrows and the two vertebrae come closer together. Adult degenerative spondylolisthesis

involves females six times more commonly than males. This form of spondylolisthesis involves

L4-L5 level four times more often than the L5-S1 level. It often causes radiculopathy related to

nerve compression within the foramen. 4

Osteoarthritis

Osteoarthritis of the lumbar spine occurs in the vertebral segments where disc height

and volume are lost and cartilage is damaged, then destroyed. In reaction to this destruction, the

bones associated with the joints develop abnormalities. Because of the potential for osteoarthritis

to grossly affect the lumbar spines cartilage and thereby its mobility, nerves may become

pinched, causing pain and, in advanced cases, numbness and muscle weakness. The patient

may also experience muscle spasms and diminished mobility. Rheumatoid arthritis, which is

an arthritic condition caused by inammation in the joints, can damage joints throughout the

body, but rarely affects the lower back. Arthritic back pain may also be caused by infections that

include Lyme disease, septic arthritis, bacterial endocarditis, Reiters syndrome, mycobacterial

and fungal arthritis, and viral arthritis.4, 8, 9

Ankylosing Spondylitis

Ankylosing spondylitis is a type of arthritis that affects the lumbar spine and in some

cases causes inammation in other areas of the body, such as the eyes, jaw, neck, shoulders,

ribs, hands, hips, knees, feet, and, rarely, the base of the heart. The disease often begins with a

swelling of the joints in the hip and lumbar spine that causes early symptoms of hip pain and

lowback pain4,5,8

. Spondylitis means inammation of one or more vertebrae. Ankylosis refers tothe stiffening of the spine that occurs after the inammation subsides, when the bone that grows

out from both sides of the joint in an effort to heal surrounds the spine and limits its movement.

Early diagnosis and treatment can control the pain, stiffness, and degree of deformity. 4

Ankylosing spondylitis that produces a chronic inammation of the spine may gradually

result in a fusion of the spine causing the patient to stoop over. In some cases it can be mild, and

16


28/31

uncommonly affects a persons ability to work. Symptoms include a slow development of back

discomfort, with pain lasting for more than three months. The back is usually stiff in the morning

and improves with activity. Ankylosing spondylitis occurs mostly in young Caucasians in their

mid-twenties and is more common in men (about 30% of the cases are in women). About 20% of

people with inammatory bowel disease and about 20% of people with psoriasis develop a formof ankylosing spondylitis. Researchers believe that ankylosing spondylitis is probably hereditary.

4

Other Considerations in the Origin of Lumbar Spine Pain:

Fibromyalgia

Fibromyalgia, thought to be caused by inammation of the brous or connective tissuealso encompasses names given to a set of symptoms that may cause chronic back pain such

as brositis and bromyositis. Widespread muscle pain, fatigue, and multiple tender points

characterize this condition. Fibromyalgia is more common than most people realize with as

many as 3% to 6% of all people having the disease. Sometimes children have bromyalgia, but it

is more common in adults, and more women have it than men do. 11

Low back pain resulting from a diagnosis of bromyalgia is real, yet also subjective.

Although the pain is present the majority of the time lasting up to years, the severity of the

pain uctuates and the location of the pain is nonspecic. Many people with this condition nd

stress increases pain. One theory suggests the mind strongly inuences the bodys immune

system. Therefore, since inammation is explained as a result of activity of the immune system,

the increased pain with stress may be a direct result. However, stress may also increase the

perception of low back pain without tissue changes. 11

Fatigue of the lumbar region is also a common aspect of this condition affecting the

lumbar spine. Most clinicians nd that the patients chronic pain and anxiety about bromyalgia

affecting the low back can be fatiguing by itself. In addition, the inammatory process occurringin the lumbar region from bromyalgia produces chemicals that are known to also cause fatigue.

In 1990, the America College of Rheumatology developed criteria for brositis that health care

practitioners can use to diagnose the condition. According to the criteria, a person is considered

to have brositis if she or he has widespread pain in combination with tenderness in at least 11 of

the 18 tender spot (trigger point) sites. 11

17


29/31

Other Considerations in Lumbar Spine Pathology:

Low back pain producing sciatica can be caused by conditions such as inammation,

abscesses, blood clots, and tumors. 1 Sometimes low back pain can be caused by problems inother organs, usually near the spine, which is then called referred pain. These conditions can

include ulcers, kidney disease, and blocked arteries. Chronic uterine or pelvic infections can

cause low back pain in women. Atherosclerosis, commonly called hardening of the arteries,

may occasionally cause chronic low back pain, because the condition reduces the supply of

blood. When it blocks arteries in the legs it may cause pain that resembles sciatica caused by

spinal stenosis. Hereditary problems affecting the lumbar spine at any age are called enteropathic

arthropathy and reactive arthropathy. Chronic arthropathy is an inherited form of arthritis that

can cause pain in the sacrum and hip joints of children and young people; it used to be grouped

under juvenile rheumatoid arthritis but is now dened as a separate problem.

Sciatica can also be caused by a condition called neurologic claudication. This is

characterized by leg pain that is less localized and sometimes associated with weakness and

numbness that increases during walking and often relieved by spinal exion. In severe spinal

degeneration, increased vertebral interosseous pressure is yet another proposed cause of pain. It

is hypothesized that in the patients with spinal stenosis a diminished supply of arterial blood to

the cauda equina is a cause of neurologic claudication. 1

18


30/31

References

1. Frymoyer JW. Back pain and sciatica. The New England Journal of Medicine. 1988;318:291-300

2. The Back Letter Vol. 12, No. 6 June 1997.

3. Coady,Catherine M and Micheli,Lyle J. Stress fractures in the pediatric athlete 1997;16:225-235.

4.Wheels Orthopedics

5. Kessler RM, Management of Common Musculoskeletal Disorders:Physical Therapy Principals and Methods.

Philadelphia Pa:J.B.Lippincott Co.;c1990

6. Southmayd W. Sportshealth: The Complete Book of Athletic Injuries. New York: Putnam Publishing Group.

c1981

7 Magee DG, Orthopedic Assessment. Philadelphia: WB Saunders; c1992.

8.Scully,Rosemary M and Barnes, Marylou R., Physical Therapy. Philadelphia, PA. J.B. Lippincott Company.;

c1989.

9. Saunders, Duane H, Evaluation, Treatment and Prevention of Musculoskeleal Disorders. Viking Press,

Minneaplis, MN. c1988.

10. Hainline, Brian, .Low back injury . Clinics in Sports Medicine.1995;14:1, 241-261.

11. American College of Rheumatology, Fact Sheet - Fibromyalgia. Prepared for Healthtouch, January 1997.Web

site: http://www.rheumatology.org

12. Berven S, Tay BB, Colman W, et al. The lumbar zygapophyseal (facet) joints: a role in the pathogenesis of

spinal pain syndromes and degenerative spondylolisthesis. Semin Neurol (United States), Jun 2002, 22(2)p187-96

13. Magee, James. Orthopedic Physical Assessment, Ed 5. Saunders Corporation. c2008.

14. Kawaguchi Y, Matsuno H, Kanamori M, et al. Radiologic ndings of the lumbar spine in patients with

rheumatoid arthritis, and a review of pathologic mechanisms.

J Spinal Disord Tech (United States), Feb 2003, 16(1) p38-43

15. Appel B. Nomenclature and classication of lumbar disc pathology. Neuroradiology (Germany), Dec 2001,

43(12) p1124-5

16. Maxey, Lisa, Magnusson, Jim. Rehabilitation for the Postsurgical Orthopedic Patient, Ed 2. Mosby, Inc.

c2007.

17. Lundon K, Bolton K. Structure and function of the lumbar intervertebral disk in health, aging, and pathologic

conditions. J Orthop Sports Phys Ther (United States), Jun 2001, 31(6) p291-303; discussion 304-6

18. Fardon DF, Milette PC. Nomenclature and classication of lumbar disc pathology. Recommendations of

the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and

American Society of Neuroradiology. Spine (United States), Mar 1 2001, 26(5) pE93-E113

19


31/31

19. Norris, Christopher, Back Stability. Champaign, IL. Human Kinetics. c2000.

20. Fardon DF. Nomenclature and classication of lumbar disc pathology. Spine (United States), Mar 1 2001,

26(5) p461-2

21. Clark P, Letts M. Trauma to the thoracic and lumbar spine in the adolescent. Can J Surg (Canada), Oct 2001,

44(5) p337-45

22. Storm PB, Chou D, Tamargo RJ, Lumbar spinal stenosis, cauda equina syndrome, and multiple lumbosacral

radiculopathies. Phys Med Rehabil Clin N Am (United States), Aug 2002, 13(3) p713-33, I

23. Botwin KP, Gruber RD, Lumbar spinal stenosis: anatomy and pathogenesis.

Phys Med Rehabil Clin N Am (United States), Feb 2003, 14(1) p1-15, v

24. McGill, Stuart. Low back disorders: evidence-based prevention and rehabilitation. Champaign, IL. Human

Kinetics. c2002.

Date post:	06-Apr-2018
Category:	Documents
Upload:	marcus-andredy-aranas-mayol
View:	237 times
Download:	0 times

Part 2 Common Pathologies of the Lumbar Spine

Documents